1

Systematic Review: Impact of an Intercalated BSc on Medical Student

Performance & Careers

Abstract

Introduction

Intercalated BScs (iBScs) are an optional part of undergraduate (UG) medicine

courses in the UK, Eire, Australia, New Zealand, the West Indies, Hong Kong,

South Africa and Canada, consisting of advanced study into a particular field of

medicine, often combined with research. They potentially improve students’ skills

and allow exploration of specific areas of interest. They are, however, expensive

for institutions and students and delay workforce entry. There is conflicting

evidence about their impact.

Methods

A mixed-method systematic review (meta-analysis and critical interpretive

synthesis) of the biomedical and educational literature, focusing on the impact of

iBScs on UG performance, skills, and career choice, and to explore students’ and

other stakeholders’ opinions about iBScs.

Results

In the meta-analytic part of this review we identified five studies which met our

predetermined quality criteria. For UG performance, two studies using different

methodologies report an improvement in UG performance; one study reported an

Odds Ratio [OR] of 3.58 [95% CI 1.47-8.83]) and the second reported a

significant improvement in finals scores (1.27 points advantage 95% CI 0.52 to

2.02). One study reported a mixed result, while two studies showed no

improvement.

Regarding skills and attitudes, one paper suggested iBScs lead to the

development of deeper learning styles. With regard to subsequent careers, two

studies suggested that for those students undertaking iBSc there is an increased

chance following an academic career [ORs of 3.6 (2.3-5.8) to 5.94 (3.6-11.5)].

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Seven of eight studies (with broader selection criteria) reported that iBSc

students were less likely to pursue GP careers (ORs no effect to 0.17 [0.07-

0.36]). Meta-analysis of the data was not possible.

In the critical interpretative synthesis analysis, we identified 46 articles, from

which three themes emerged; firstly, the decision to undertake an iBSc, with

students receiving conflicting advice; secondly, the educational experience, with

intellectual growth balanced against financial costs; finally, the ramifications of

the iBSc, including some suggestion of improved employment prospects and the

potential to nurture qualities that make “better” doctors.

Conclusion

Intercalated BScs may improve UG performance and increase the likelihood of

pursuing academic careers, and are associated with a reduced likelihood of

following a GP career. They help students to develop reflexivity and key skills,

such as a better understanding of critical appraisal and research. The decision to

undertake an iBSc is contentious; students feel ill-informed about the benefits.

These findings could have implications for a variety of international enrichment

programmes.

Plain language summary

Intercalated BScs courses usually involve an extra year at medical school with a

focus on research, and exist in many forms and in many countries. They are

expensive for students and institutions and delay students starting work as a

doctor. There is debate about their impact. We undertook a systematic review of

the research that had gathered the views from student and teacher sources

about these courses. Amalgamation of the data suggested that these courses

may have a beneficial impact on student performance at medical school,

students who do them are more likely to be clinical academics (clinical teachers

or researchers), and are less likely to be general practitioners. Contextual data

suggested that if students have a choice (which not all do), they find it a difficult

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decision balancing possible career benefits against the extra costs. Most usually,

they find the courses very helpful.

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A Systematic review of the impact of intercalated BSc on medical students’

performance and career choices

Background and need for the project

Medical schools aspire to produce fully rounded clinicians, with skills such as

scientific literacy, self directedness in learning and motivation to explore specific

areas of interest. There is, however, limited scope within crowded medical school

curricula for medical students to develop these skills and interests as

undergraduates. Self directed courses (Murphy et al. 2008), summer research

projects (Griswold et al. 1991;Kemph et al. 1984) and other initiatives have had

varying degrees of success; however, an additional degree during protected time

within the undergraduate medical curriculum has the potential to meet many of

these objectives.

Intercalated, honours, honors or complementary BScs and BMedSci courses

(collectively called iBScs from here on) are usually periods of extended study

during a medical undergraduate (UG) course, usually with a focus on a specific

area of preclinical or clinical science. Intercalated BScs are undertaken in

addition to basic undergraduate medical training and aim to give future clinicians

important extra skills and experience. Traditionally, in the UK, iBScs have been

offered only to the most academically able students, usually at the end of the pre-

clinical course and in basic science subjects, such as physiology and anatomy.

They were an expected right of passage for some students intending to pursue

highly competitive careers (Park SJK et al. 2010) (Jones M et al. 2005). More

recently, some UK institutions, such as University College London (UCL) and

Southampton University, have made these courses compulsory for non-graduate

entrants. In other UK institutions (such as Nottingham University) these degrees

are obtained as standard elements of attainment within an ordinary medical

school degree, often as a B Med Sci.

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As an educational intervention, iBScs often share the following properties: an

extended course away from the traditional medical curriculum, (Collins et al.

2010) encouraging in depth independent study (Yudkin et al. 2003), a project

focusing on an area of interest (Gardner K and Olojugba C 2008), e.g. a

laboratory based project (Krishnan P 2002b), or a formal dissertation (Jones M et

al. 2008). In some cases, they feature clinical work (Jones M et al. 2001;Park

SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010).

Published iBScs course aims often suggest producing clinician scientists, rather

than teaching enhanced skills for clinical practice. One UK iBSc course describes

the degree as “research orientated” providing “good training in the techniques

and methods of biomedical research” (page 216) (Tait N and Marshall T 1995).

One Australian course has multiple learning objectives, including “the process of

research work, critical appraisal, development of skills about knowledge

(evidence), how it should be assembled and evaluated and updated, encourage

oral and written communication skills, and development of autonomy and

independence in study”. (page e542) (Collins, Farish, McCalman, & McColl

2010).

There are a range of iBSc courses available, including traditional preclinical

sciences (physiology (Harris PF 1986), anatomy (Gogalniceanu et al. 2009),

biochemistry, (Fraser et al. 1986) pathology (MacGowan AP et al. 1986;Wyllie

and Currie 1986), as well as clinical subjects, such as microbiology, public health

and primary care (Elwood et al. 1986;Jones M, Lloyd M, & Meakin R

2001;Williamson JD 1986). Various course descriptions have been published

(Broome JL et al. 2007;Collins, Farish, McCalman, & McColl 2010;Dudley HAF

1970;Dudley HAF 1989;Jones M, Lloyd M, & Meakin R 2001;Jones M, Singh S,

& Lloyd M 2005;Yudkin, Bayley, Elnour, Willott, & Miranda 2003). A full list of the

range of current UK intercalated BScs are available at www.intercalate.co.uk.

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Intercalated BSc programmes are delivered in the UK, Australia (Collins, Farish,

McCalman, & McColl 2010;Eaton and Thong 1986;Ludbrook 1989;Young JA and

Sefton AJ 1984), New Zealand (Al-Shaqsi S 2010;Park SJK, Liang MMS,

Sherwin T, & McGhee CNJ 2010) Hong Kong, the West Indies (Jamaica), South

Africa (Baleta 2012) Eire, and occasionally Canada (Gerrard et al. 1988)

(Fingerote RJ 1989).

Table 1: Examples of international intercalated iBScs

Country University Web address

Australia University of

Sydney

(http://sydney.edu.au/science/fstudent/undergrad/course/com-

scimed.shtml) (tinyurl.com/6k3k4aw),

New Zealand Otago (http://www.otago.ac.nz/courses/qualifications/bmedschons.html)

(tinyurl.com/658m3tm).

Republic of

Ireland

University

College Cork

http://www.ucc.ie/medstud/YearInt/yearintercalate.html

Jamaica University of the

west Indies

http://sta.uwi.edu/resources/documents/facultybooklets/MedSciUndergrad.pdf

Hong Kong The Chinese

University of

Hong Kong

http://www.med.cuhk.edu.hk/v7/Doc/BMedSc%20Information%20Sheet%202008.pdf

South Africa UCT (Cape

Town)

http://www.medicine.uct.ac.za/Clinical%20Scholar/Presentations/11H30%20AKatz.ppt

Canada University of

Manitoba

http://umanitoba.ca/faculties/medicine/education/undergraduate/bsc_med.html

There are also various blogs discussing iBScs.

(http://blogs.bmj.com/bmj/2010/04/14/helen-jaques-to-bsc-or-not-to-bsc/)

(tinyurl.com/bmsey8c),

(http://www.thestudentroom.co.uk/wiki/A_Brief_Guide_to_Intercalated_Degrees)

(tinyurl.com/6vz75o9)

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Intercalated BScs have a long history, dating back to the 1890s in Australia

(Young JA & Sefton AJ 1984), and were introduced formally in the UK in 1964

(Smith 1988). By 1985, 10% of UK medical graduates had a Bachelor of Arts or

BSc (which may or may not have been intercalated), as did 39% of medical

academics (Wakeford et al. 1985). The last published estimate suggests iBScs

are undertaken by between 10% and 36% of UK medical students (McManus IC

et al. 1999;Tamber PS 1986). Until 1986 they were explicitly funded in the UK by

the Medical Research Council (MRC) with the intention of seeding new clinical

academics; a role they still fulfil in other countries (Baleta 2012). In the UK they

are still widely offered, with 230 iBScs listed on the intercalate.co.uk website

(accessed October 2012).

There is little published about why departments offer such courses. There may

be an element of being a “shop window” to attract future medical academics,

“departments often find that successful students return to the discipline after

qualification”” (p125) (Fraser, Browning, Walsh, & Paterson 1986), and there may

be altruistic reasons with faculty wanting to see future clinicians better equipped

to undertake or understand research, “departments …welcome the opportunity of

covering their subjects in depth and of training students in scientific methods”.

(p125) (Fraser, Browning, Walsh, & Paterson 1986), funding advantages for

departments, such as bringing in teaching income, and there may be a desire to

increase departments’ prestige and status by delivering these high profile

courses.

In many countries, following a US model of medical education, primary medical

courses are usually postgraduate, so there would be very limited student appeal

for a faculty in offering an undergraduate intercalated BSc, but as discussed

further on, intercalated higher degrees (PhD, MPH) are now being offered.

Enrichment programmes that extend medical school courses exist extensively in

the US, although these programmes are designed primarily to enhance access to

medical degree courses for minority groups (Barzansky et al. 2000).

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Programmes called complementary degrees also flourished in the 1970s, in the

form of six year BSc, MD courses; again, aimed at promoting access to

medicine. (Daubney JH et al. 1981)

Research programs that extend medical courses with research methods

programmes and projects or dissertations are common in the US, (Jacobs and

Cross 1995) and these are often undertaken as summer courses (Griswold,

Silverstein, Lenkei, & Fiedler 1991;Kemph, Claybrook, & Sodeman, Sr. 1984).

They also exist in Canada (Smith et al. 2001), Germany (Cursiefen et al. 1995),

Croatia (Kolcic et al. 2005) and Finland (Remes et al. 2000). These research

courses have some similarities with iBSc courses, and these courses are

sometimes constructed for the completion of dual clinical / higher research

degrees (MD /PhD, MD /MPH) (Andriole et al. 2008) (Creavin et al. 2010).

Table 2 Examples of intercalated medical and higher degrees

Country University Course Web address/ reference

Scotland/

UK

St

Andrew’s

MRes http://medicine.st-

andrews.ac.uk/documents/MRes_Leaflets_Feb11.pdf

UK Keele Masters Creavin (Creavin, Mallen, & Hays 2010)

USA Various MD

/PhD

Andriole (Andriole, Whelan, & Jeffe 2008)

UK UCL MB/PhD http://www.ucl.ac.uk/mbphd/

NZ Auckland MB PhD

others

Park (Park SJK, Liang MMS, Sherwin T, & McGhee

CNJ 2010)

Student selected components (SSCs) in UK medical schools that offer some of

the components of an iBSc, such as depth and breadth of study, a foray into

areas of personal interest, and provide opportunities outside the standard

medical arena, but often last only a few weeks (Whittle and Murdoch-Eaton

2002) (Murphy, Seneviratne, Mcaleer, Remers, & Davis 2008).

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Where there is a choice, the decision whether to undertake an iBSc remains a

substantial dilemma for many medical students (Nicholson et al. 2010). iBSc

courses are expensive in terms of the opportunity cost of delayed graduation and

entry to the medical workforce, as well as direct costs due to student fees, living

expenses and faculty costs (teaching and supervision) (Fraser, Browning, Walsh,

& Paterson 1986). Estimates of the total additional costs in the UK are £40,000

per student (Gutenstein M 2000) (Sastry T 2005). Collins quotes iBSc course

fees of Aus $5000 (Collins, Farish, McCalman, & McColl 2010). With such high

costs, it cannot be assumed that ‘optional’ degrees will remain the norm in a

current climate of austerity. The role of the iBSc in medical education has

therefore become more pertinent, particularly in the UK, in light of recent

reductions in government funding for UK higher education and higher course

fees.

Previous reviews on this subject are available (Leung W 2001) (Collins, Farish,

McCalman, & McColl 2010) and discussed later. There is little data about the

expected impact of iBSc courses. The following phrase from an editorial, “doing

an intercalated BSc can make you a better doctor” (p760) (Greenhalgh and

Wong 2003), which we have operationalised as: improved exam performance,

skills acquired and the impact on students’ subsequent careers. This structure

has been used to frame the aims of our review, as follows.

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Aim: To undertake a systematic review of the published literature on the impact

for students undertaking a BSc, specifically focusing on the following:

students’ decisions about undertaking an iBSc;

students’ performance in undergraduate or final exams;

impact on students’ professional skills and values;

students’ experiences of doing an iBSc;

effect on students’ career choices;

the ramifications (financial, personal) for students of doing an iBSc.

Methods

A systematic review with two components was undertaken to explore the impact

of iBScs in medical education synthesising data from qualitative and quantitative

methodologies (Adamson J 2005). A traditional meta-analysis (reporting

numerical data) and a critical interpretative synthesis (reporting qualitative data)

were undertaken, each with its own pre-specified criteria (see table 3). The

published literature was searched using the following databases: Medline /

National Library of Medicine (NLM), PsychINFO, EMBASE, the student BMJ

database and ERIC for papers that report student outcomes beyond the direct

course outcome itself - such as degree class or result. In addition, we manually

searched archived Student BMJs, as an established source of articles and UK

student perspective on iBScs. Index papers were citation-tracked using ISI Web

of Knowledge. We subsequently checked the search with a Google Scholar

search using the search term “intercalated bsc”.

Once the two analyses were complete we combined the resulting data. We have

not placed either process within a methodological hierarchy (i.e. quantitative data

is stronger than the qualitative) but took the view that we would combine data in

a complimentary manner, using an “integrationist approach”, (p232) (Adamson J

2005) so that the data that illustrates a given concept or issue is used regardless

of its source.

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Scope of review

We have restricted our review to intercalating degrees at a Bachelor’s level for

medical students (and so we have excluded Veterinary or Dental science iBScs).

Intercalating higher degree programmes such as intercalated Masters and MB /

PhD programmes (see table 2) exist but are not included as they are relatively

new, are not well evaluated currently (so there is little published material on their

impact to include in a systematic review), and are probably likely to be aimed at

clinicians predominantly pursuing a research rather than primarily a clinical

career. We have also excluded undergraduate research courses and special

study modules (SSC / SSMs), as these are very heterogeneous in nature and

vary in duration from a few days to several years. US enrichment and Medicine

Access courses are excluded, as previously discussed.

Search terms

The following search strategy was used and adapted for each database. The

following is an example of the NLM / Medline search.

1. medical student AND (outcome OR progres$ OR exam OR succes$ OR

fail$) = 2341

2. bsc OR bachelor OR degree OR intercalated [Text Word] OR honours

[TW] OR honors [TW] OR complementary [TW]= 430317

3. Combined 1&2 = 158 citations

Criteria for entry

We set the following inclusion criteria for the meta-analysis / quantitative

synthesis: i) observational or trial designs, ii) controlled for previous academic

performance, iii) a focus on undergraduate medical students, iv) outcomes

compared with the general undergraduate and graduate medical population, and

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v) availability of an English language abstract vi) an adequate description of the

course to allow a judgment on the similarity with UK iBSc degrees.

For exploration of data on the impact of iBScs on pursuit of GP/ hospital careers

we have dropped criterion ii), as we felt adjusting for prior academic performance

(i.e. producing a ranking of students) would be meaningless on this measure as it

is impossible on the other side of the analysis to rank the merits or produce a

hierarchy of different medical careers.

For the meta-analysis / quantitative synthesis, studies were reviewed by two

researchers and data analysis was checked independently by a statistician. We

anticipated conducting meta-analysis of the data if they were not heterogeneous.

Forest plots (Clark O and Djulbegovic B 2001) were derived.

For the critical interpretative synthesis (CIS) (Dixon-Woods et al. 2006)

component of this review we set the following criteria:

1) Research papers, letters, opinion pieces and other articles (grey literature)

relating to intercalated degrees within the medical undergraduate course.

2) Date range 1.1.1984 - 1.11.2012 to link with more recent student

experiences and to allow adequate capture of the surge of opinion pieces

before and after the timing of the UK Medical Research Council’s (MRC)

withdrawal of funding to iBScs in 1986.

3) Data identified from the meta-analysis / quantitative synthesis were

included, when they contained reflective comments on their results.

CIS uses a wide variety of data sources such as letters and opinion pieces but is

not a meta-synthesis of qualitative studies. The selection criteria do not therefore

require any judgement about the “quality” of the source material; the aim is “to

prioritise papers that appeared to be relevant, rather than particular study types

or papers that met particular methodological standards” so that the data can act

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“to maximise the inclusion and contribution of a wide variety of papers at the level

of concepts” (page 4) (Dixon-Woods, Cavers, Agarwal, Annandale, Arthur,

Harvey, Hsu, Katbamna, Olsen, Smith, Riley, & Sutton 2006).

Table 3: data sources and criteria for both methodological sections of the review

Meta-analysis critical interpretative synthesis

Data source Studies identified through searches of Medline/National Library of

Medicine (NLM), PsychINFO, EMBASE, the student BMJ database, ERIC

Search criteria medical student AND (outcome OR progres$ OR exam OR succes$ OR

fail$) , bsc OR bachelor OR degree OR intercalated [Text Word] OR

honours [TW] OR honors [TW] OR complementary

Dates No date range applied, searches

undertaken in 2008 and updated in

2012.

Additionally we incorporated

research papers, letters,

opinion pieces and other

articles relating to intercalated

degrees within the medical

undergraduate course.

Date range 1.1.1984 -

1.6.2009 updated 1.11.12

Quality criteria observational or trial designs, ii)

controlled for previous academic

performance, iii) a focus on medical

students, iv) outcomes compared to the

general under and graduate medical

population, and v) availability of an

English language abstract vi) an

adequate description of the course.

CIS methodology does not

require assessment of quality

of primary data sources, just

the ability the data has to help

generate concepts.

Analysis

i) Meta-analysis / quantitative synthesis:

The data is reported as odds ratio (OR) of BSc students’ performance ÷ non-BSc

students. Where ORs are very wide, logs OR are used to visually represent the

data. Where identified studies did not report their data in the form of ratios, the

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data are compared to other published work; for example, career outcome (%

iBSc / non iBSc students going into general practice [GP]), or undergraduate

performance.

ii) Critical interpretative synthesis:

With the critical interpretative synthesis of the qualitative data, this was analysed

by two researchers (PH and SE) using a thematic framework approach (Ritchie.J

and Spencer E 1994).

The researchers independently familiarised themselves with the data, each

constructing a preliminary framework of emergent themes, which were then

modified and combined by consensus, and subsequently checked by a third

researcher (MJ), who was familiar with the qualitative data. The data were then

indexed according to the themes. In the form of excerpts, the data were then

charted onto an Excel spreadsheet according to theme, seeking disconfirming

evidence throughout, and modifying themes accordingly. All disagreements in

interpretation were discussed until consensus was achieved.

Results

The data and themes of this review are presented in a chronological order that

might follow a student’s career and are not presented by the methodology from

which they were obtained.

Data was organised under the following headings:

1. The students’ decision to undertake an iBSc

2. Undergraduate performance

2.1 Acquisition of additional skills

3. Student experience

4. Impact on students’ careers

4.1 Future ramifications of having taken an iBSc

4.2 Career progression

4.3 Impact on GP careers

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Data from the meta-analysis are embedded within the overall results as part of

the following themes: impact on undergraduate performance (theme 2),

acquisition of skills (sub theme 2.1), impact on students’ careers (theme 4),

academic careers (sub theme 4.2) and impact on choosing GP careers (sub

theme 4.3).

i) Meta-analysis/ quantitative synthesis:

For this element of the review we initially identified 19 papers (see appendix 1)

(Cleland et al. 2009;Eaton & Thong 1986;Elwood 1986;Elwood, Pearson,

Madeley, Logan, Beaver, Gillies, Little, & Langham 1986;Gerrard, Fish, Tate, &

Fish 1988;Harris PF 1986;Lambert et al. 2001;MacGowan AP, Johnston PW, &

Thomson AW 1986;McManus IC, Richards P, & Winder B.C 1999;Nade

1978;Nguyen VanTam J et al. 2001;Tait N & Marshall T 1995;Williamson JD

1986;Wyllie & Currie 1986;Young JA & Sefton AJ 1984) (Howman and Jones

2011) (Mahesan et al. 2011) (Collins, Farish, McCalman, & McColl 2010)

(Wakeford, Evered, Lyon, & Saunders 1985) reporting student impact

(undergraduate performance, skills and attitudes and subsequent career

progression), of which five met our full quality criteria for undergraduate

performance (see table 4 and appendix 1). (Tait N & Marshall T 1995) (Wyllie &

Currie 1986) (Cleland, Milne, Sinclair, & Lee 2009) (Mahesan, Crichton, Sewell,

& Howell 2011) (Howman & Jones 2011) The papers are described in more

detail in appendix 1. The studies were methodologically heterogeneous, so we

were not able to produce a pooled (or meta-analysed) result.

ii) Critical interpretative synthesis:

For this element of the review we identified 46 papers, letters or articles which

were deemed to be relevant to the subject of the review from an original search

containing 485 items. The papers are described in detail in appendix 2. From this

data we generated three main themes: the decision to undertake an iBSc (theme

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1), the experience of doing an iBSc (theme 3), and the future ramifications of

having undertaken the degree (sub theme 4.1).

1. The decision to undertake an iBSc

From our critical interpretative synthesis of the qualitative data, we found

evidence that iBScs were pursued by students interested in research and

academic medicine and in the expectation that these courses would help their

career. (Park SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010). Within the

literature there is, however, debate about whether, for some students, they

should undertake an iBSc at all.

‘The only exception was that if you are a student interested in going into

research the article provided a fairly clear answer: “yes”… (otherwise with

regard to iBScs and careers) The answer was elusive, it is now no

clearer.” (Student) (page 478) (Aston D 2001)

Our data suggest that iBScs are a sensible choice in terms of career

enhancement for some careers, but uncertain for others (GP, psychiatry). From

a strictly career enhancing perspective there was some doubt about the impact of

undertaking humanities iBScs. These themes are reflected by the following:

‘In short, either decision, to do or not to do, can be the right one for you.’

(Student) (page 479) (Burkitt Wright EMM 2001)

“For those intending to pursue a clinical career in… psychiatry, general

practice – you should consider whether your desire for intellectual

stimulation outweighs the time and money constraints” (doctor and medical

journalist) (page 419) (Leung W 2001)

Structural factors also influenced the choice, such as the medical school’s policy

on compulsory courses, the nature of course offered or prior academic success.

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‘The proportion of students taking the intercalated degrees varies widely

among medical schools. In some medical schools it is obligatory... In other

schools, it is open only to students who performed well in the first two years.’

(Doctor and medical journalist) (page 418) (Leung W 2001)

Lack of advice and support to students from medical schools was also

highlighted as an issue (Park SJK, Liang MMS, Sherwin T, & McGhee CNJ

2010).

2 Undergraduate performance

We identified five papers that report the impact of iBScs on medical school exam

performance (Table 4 & Figure 1) (Tait N & Marshall T 1995) (Wyllie & Currie

1986) (Cleland, Milne, Sinclair, & Lee 2009) (Mahesan, Crichton, Sewell, &

Howell 2011) (Howman & Jones 2011) with two reporting improvement in UG

performance; Wyllie reports ORs of 3.58 (1.47-8.83). Mahesan et al’s reports that

“internally intercalating students had a year 5 mean result that was on average

coefficient of 1.27 points (95% CI 0.52 to 2.02) greater than non intercalating

students”, externally intercalating students showed a non significant increase (the

range of the data, however, was not published). It was not possible to calculate

an OR from this data.

The study by Tait (Tait N & Marshall T 1995) reports that some factors in student

performance improved, while others did not; but insufficient data was reported to

derive an OR for this study. Cleland et al.’s study looked at multiple measures,

but reported a non significant improvement in finals OSCEs. (Cleland, Milne,

Sinclair, & Lee 2009) Howman et al.’s paper in a medical school where iBScs are

compulsory (minimising selection bias) suggests there is no effect on first clinical

year performance with an adjusted mean score difference of 1.4 (-4.9 to +7.7

95% CI, p=0.66) (overall mean score 238.0 “completed iBSc” students versus

236.5 “not completed” range 145 - 272 out of 300). (Howman & Jones 2011). In

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summary, two studies out of five reported an improvement in UG performance

associated with undertaking an iBSc.

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Table 4: Impact of the iBSc degree on undergraduate medical student

performance

Study Measure BSc

students

Non BSc

students

Odds

ratios

95%

Confidence

intervals

Wyllie et al

1986

Finals (getting high score in

finals exam) >10/20

32/55

(58.2%)

14/50

(28%)

3.58 1.47-8.83

Cleland et

al 2009

% achieving highest grade

(1-2) in OSCE finals (861

students)

104/154

(67.5%)

421/707

(59.5%)

1.41 0.96-2.09

Howman

et al 2011

1st clinical year score - top

half

53/136

(38.9%)

37/138

(26.8%)

1.81 1.09 to 3.01*

(*note

adjusted

score is n/s)

Tait et al

1995

Data in unusable format- narrative summary

Mahesan

et al 2011

Finals score Internal intercalating students scored 1.27 points (95% CI 0.52 to 2.02) greater than those who did not .

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Figure 1: Impact of the iBSc degree on undergraduate medical student

performance (diagram does not include data on two studies for which ORs

weren’t calculable)

2.1 Acquisition of additional skills and changes in attitudes

Our analysis showed that one of the most frequently cited benefits of undertaking

an iBSc was the acquisition of new skills, (Agha and Howell S 2005;Asgari-

Jirhandeh and Haywood 1997;Iqbal K 2001;Krishnan P 2002b) (Park SJK, Liang

MMS, Sherwin T, & McGhee CNJ 2010) specifically including research or

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laboratory skills that are rarely learnt elsewhere in the curriculum (White R 2006)

(Mabvuure 2012). Students and academics cited the improvement to critical

appraisal skills from handling literature during the year, (Attwell and Boyd

1996;Iqbal K 2001;Jones M, Singh S, & Lloyd M 2005) (Weidmann A 2002) and

a variety of personal study skills, such as self-discipline and time management

(Elwood, Pearson, Madeley, Logan, Beaver, Gillies, Little, & Langham 1986;Price

H 1998). Empathy (Moscrop A 2002) and improved communication skills were

also mentioned with reference to iBScs with a clinical component. In Elwood’s

study 34/98 [35%] of students mentioned improvements in interpersonal skills,

such as “the ability to talk to patients” (page 233) (Elwood, Pearson, Madeley,

Logan, Beaver, Gillies, Little, & Langham 1986). Additionally, the opportunity for

independent intellectual thought and stimulation was highlighted (Williamson JD

1986) (Elwood 1986).

We also investigated the impact that iBScs had on students’ skills and attitudes

within the quantitative framework and identified only three studies (two of high

quality). McManus et al. report that students who had taken an intercalated

degree had higher deep learning scores (z = 3.73, P < 0.001) and strategic (z =

4.56; P < 0.001) (where the significance tests from multiple regression and

multilevel modelling are reported as Z statistics). (McManus IC, Richards P, &

Winder B.C 1999) However, one study suggested a deterioration in the way

students deal with ethical issues, following the iBSc (Goldie et al. 2004).

Additionally, Elwood et al’s study (student self-reports, with no comparator

groups so not meeting our quality criteria) found that 90% (81/90) respondents

believed that the course promoted their interpersonal skills as well as their

research skills, and 58% (57/98) reported an increased awareness of the need

for critical evaluation (Elwood 1986;Elwood, Pearson, Madeley, Logan, Beaver,

Gillies, Little, & Langham 1986).

Of interest to students and societal stakeholders is the question of whether

undertaking an iBSc makes better doctors (Agha and Singh 2003) (Greenhalgh &

22

Wong 2003). Academic leaders felt that iBScs instilled skills that were highly

valuable to future doctors (Greenhalgh & Wong 2003). However, with no agreed

measure of a “good doctor,” there is, unsurprisingly, no hard evidence to support

or refute this as a potential outcome.

3. Student experience

Students often described the courses as being enjoyable and some felt it had

had a profound effect on their lives, (Harris PF 1986) (Goldstein D 2002;Holmes

1986;Smith 1986) due to intellectual rewards or influence on career:

"That was the year that I learnt to think and to question and to find out

things for myself. That is where the (iBSc) degrees may be so important

they prepare students for a lifetime of learning” (former editor of the BMJ)

(page 1620) (Smith 1986)

Also mentioned was the opportunity to have a break from the rigours of the

medical course, although perceived workloads varied considerably. (Krishnan P

2002b) (White R 2006) (Moscrop A 2002). Some students discussed the chance

to form new friendships, (White R 2006) (Weidmann A 2002); however, others

described the loss of social networks from the early years of medical school as a

drawback (Park SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010)

(Thiagamoorthy S 2001).

The key negative aspect to undertaking an iBSc internationally were the

additional financial costs (Fingerote RJ 1989;Gardner K & Olojugba C 2008;Gray

1989;Gutenstein M 2000;Park SJK, Liang MMS, Sherwin T, & McGhee CNJ

2010).

“With mounting student debt and moves by the UK government to almost

triple tuition fees… accumulating yet another year’s debt whilst also

23

delaying repayment of your growing negative balance can be a serious

turn-off.”(Recently qualified doctor) (page 1137) (Rushforth 2004)

Various practical problems were mentioned, such as students’ concerns about

not being able to pursue preferred subjects. There were faculty worries over the

potential adverse impact on students’ clinical skills, although in one study

comparing those who intercalated and those who didn’t, intercalating students

achieved higher clinical OSCEs scores than those who didn’t intercalate

(Cleland, Milne, Sinclair, & Lee 2009).

Students voiced worries about their research not producing meaningful results,

and some described a pressure to publish (Collier K 2001). There were

contrasting views on the quality of support from supervisors (Eaton & Thong

1986) with occasional voices expressing concerns about being exploited in

laboratory settings (although in this specific case the published accusation

(Krishnan P 2002b) was contested (Kentish JC and Avkiran M 2002) and

subsequently retracted (Krishnan P 2002a).

4 Impact on students’ careers

Our analysis suggests there was a perceived benefit to general employment

opportunities (Agha & Howell S 2005;Park SJK, Liang MMS, Sherwin T, &

McGhee CNJ 2010), particularly within the specific discipline of the iBSc subject.

(Child M and Gupta L 2009) However, the impact on employment of an iBSc was

also contested by some commentators.(Collier K 2001;Leung W 2001)

“No value put on the (intercalated) degree once you qualify” (page 30)

(Park SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010)

IBScs were perceived to confer advantages for candidates, in terms of useful

personal contacts (Park SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010),

24

impact at interview (Iqbal K 2001) and within their employment references (Leung

W 1999). Additionally, iBScs explicitly gain extra credit within the application

system for the UK Foundation post system for junior doctors. Mahesan et al.’s

study (Mahesan, Crichton, Sewell, & Howell 2011) showed that iBSc students

obtain higher scoring for their foundation school application, both from their

improved exam performance, but also though improved scoring on “white space”

(page 2) (Mahesan, Crichton, Sewell, & Howell 2011) question (“white space”

online questions are free text reflective questions about team working,

professionalism, etc asked of all applicants for foundation training - however this

assessment format will disappear in 2013).

There was discussion about whether some careers really warranted an iBSc

(Longmore HJA 1986), linking back to the decision to undertake an iBSc in the

first place. For those students undecided about their future career path, the

suggestion was that iBScs were a sensible choice, particularly if aiming to branch

away from medicine altogether as it gave students an exit degree without having

to wait 5-6 years for a Medicine degree (Leung W 2001).

4.2 Academic career progression (the pursuit of an academic career)

We know that those who have already pursued UK and international academic

careers are more likely to have iBScs (Evered et al. 1987;Wakeford, Evered,

Lyon, & Saunders 1985) (Seltzer 1987). A methodological difficulty was

highlighted by authors in ascertaining a causal relationship between undertaking

an iBSc and success in academic careers (Holgate J et al. 1999) (McManus

2011). The potential for students to attain publications from their research was

mentioned as being a key benefit that enhanced career prospects. (Agha &

Howell S 2005;Park SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010) At

Queensland (Australia) Medical school iBSc graduates were 6 times more likely

to undertake higher research degrees (MSc, MD, PhD) [17.3% vs 3% (p<0.001)]

compared to non-intercalating students (Eaton & Thong 1986). The mechanism

may be that an iBSc degree,

25

“confers a significant advantage when applying for post graduate medical

research scholarships to do a PhD, MD or MS”. (page 907) (Ludbrook

1989)

There is evidence that the intention to pursue an academic career is present at

the undergraduate level - suggesting the iBSc merely acts as staging post for

aspiring academics (McManus IC, Richards P, & Winder B.C 1999) (McManus

2011).

There is some suggestion that departments run such courses to attract clinical

academics back to their speciality and to build academic capacity (Fraser,

Browning, Walsh, & Paterson 1986). There are also concerns that the threats to

iBScs courses may have an adverse impact on academic capacity (Morrison

2004).

We identified three studies within the quantitative element of the review which

indicate that students with an iBSc have improved prospects of academic

progression (Table 5, figure 2) with ORs in the range 3.64 (95% CI 2.32-5.77) to

5.94 (95% CI 3.60-11.54). (Gerrard, Fish, Tate, & Fish 1988) (Wyllie & Currie

1986). McManus reported a career preference to pursue “medical research”

amongst final year students of 2.18 (sd 1.10) for iBSc students vs 1.71 (sd 0.88),

p<0.001 (on a range of 1-5 where 5 indicates a definite intention to pursue this

career) (McManus IC, Richards P, & Winder B.C 1999). There was insufficient

data to calculate an OR for this study. Additionally, the Nguyen study states that

“55% reported that the (honours) year had increased their likelihood of choosing

an academic career”, however, 19% “felt it had reduced the chances.” (page 136)

(Nguyen VanTam J, Logan RF, Logan S, & Mindell J 2001).

26

Table 5: Impact of iBSc degrees on academic advancement - i.e.

encouraging students to pursue academic careers.

Study Measure B.Sc

students

Non B.Sc

students

Odds

ratios

95%

Confidence

intervals

Gerrard et

al 1988

Academic

career

101/206

(49%)

43/206 (21%) 3.64 2.32-5.77

Wyllie et

al 1986

Academic

careers

18/42

(43%)

321/2863**

(Lambert and

Goldacre

1998)

(11.2%)

5.94 3.60-11.54

** expected proportion of academics from Lambert (Lambert & Goldacre 1998)

27

Figure 2: Impact of iBSc degrees on academic progression (the pursuit of

an academic career)

1 10 100

Gerrard

Wyllie

Log Odds Ratio

favours academic career-->

28

4.3 GP careers

There is an association of students with iBSc degrees and a lower likelihood of

pursuing careers in GP / family practice (Table 6 & Figure 3), with many iBSc

graduates instead pursuing hospital careers - OR for a GP career ranged from

0.99 (OR confidence intervals cross unity) to 0.17 (0.07-0.36).

McManus et al stated iBSc students “showed … less interest in general practice”

(page 542) with a career intention of 2.27 (sd 0.83) for iBSc students vs 2.46 (sd

0.88), p<0.001 (on a range of 1-5 where 5 indicates a definite intention to pursue

this career) (McManus IC, Richards P, & Winder B.C 1999). These results may

be explained by an historical lack of primary care-related BSc degrees – courses

that now exist (Jones M, Lloyd M, & Meakin R 2001) – supported by the fact that

the most community-orientated iBSc (public health and epidemiology) has no

negative effect on GP recruitment (Nguyen VanTam J, Logan RF, Logan S, &

Mindell J 2001).

29

Table 6 Impact of iBSc degrees on general practice as a career

* expected proportion to follow a GP career (Lambert et al. 1996)

** estimated from proportions in report, no raw data

Study Measure BSc students Non-BSc

students

Odds ratios 95%

Confidence

intervals

Gerrard et al

1988

% family practice 17**/336 (5%)

215/ 1442

(13%)

0.36 0.20-0.60

Eaton et al

1986

% general practice

careers

11/90 (12.2%) 51/112

(45.5%)

0.17 0.07-0.36

MacGowan A

1986

% general practice

careers

9/46 (19.5%)

* 528/1192

(44.3%)

0.31 0.13-0.65

Nguyen Van

Tam J et al

2001

% general practice

careers

86/ 195 (44%)

* (44.3%) 0.99 0.72-1.36

Williamson JD

1986

% general practice

careers

3/19 (15.7%) * (44.3%) 0.24 0.04-0.83

Wyllie et al

1986

% general practice

careers

7/42 (17%) 16/39 (41%) 0.29 0.09-0.89

Young & Sefton

1984

% general practice

careers

31/356 (8.7%) 51/112

(45.5%)

0.11 0.07-0.20

Lambert et al

2001

% general practice

careers

319/2081

(15.3%)

776/ 2992

(25.9%)

0.52 0.45-0.60

30

Figure 3: Impact of iBSc degrees on subsequent careers in general practice

Discussion

This study is the first attempt to systematically analyse the benefits of iBSc

courses within UG medical education. This review showed conflicting evidence

that undertaking an iBSc degree may have on undergraduate performance and

acquisition of additional skills (this evidence is open to interpretation and is

discussed further on). Though students may find the decision to undertake an

iBSc difficult, there were suggestions that these courses were likely to benefit the

future careers of some, in particular, those aspiring to an academic career. While

students with iBScs are more likely to pursue careers in academia or hospital

medicine, such choices do not necessarily indicate that these courses yield

better doctors.

0.01 1

Young

Eaton

Williamson

Wyllie

MacGowan

Gerrard

Lambert

Nguyen

Log Odds Ratio

<-- favours non GP career

31

The primary studies that reported results from the CIS data add crucial context in

this area, with suggestions of improved intellectual development, the time for

students to reflect on their own skills, to develop life-long learning skills and “to

get (their) head around research” (Greenhalgh & Wong 2003). These are not

attributes that should be optional in medicine and are traditionally not well

delivered by normal curricula (Tonks A and et al 2002;Watmough et al. 2009).

Beyond the institutional and societal focus, however, the area of the results that

may appeal to students (and consumers) of iBScs may relate to improved

employment prospects, and more intangible components of spending a year

away from the medical course, being another year older before qualifying as a

doctor and working at a different pace. The uncertainty many students face about

the choice to undertake an iBSc, where the course is optional, highlights the

need for good careers advice (Nicholson, Cleland, Lemon, & Galley 2010;Park

SJK, Liang MMS, Sherwin T, & McGhee CNJ 2010;Rushforth 2004) so that

students can make an informed choice relative to their own career plans.

Limitations

We have concluded on the basis of the data presented (supported by the CIS

data), that overall, there is a positive effect on UG performance from iBScs.

However, synthesising data across different study designs and methodologies is

problematic (Adamson J 2005). From within the quantitative analysis, two out five

studies suggest an improvement in UG performance but the data is not meta-

analysable, so it is impossible to say what an overall result would be, were it

possible to pool the data. Importantly, none of these studies suggest an adverse

impact; it is a question of are these studies underpowered to detect a difference

(effect not found) or is there is no difference (no effect)? Balancing the overall

effect of two positive studies with three no difference studies has, therefore, to be

a subjective and open to interpretation. Similarly, how we interpret and integrate

the results from the CIS data, where qualitative data are traditionally within one

epistemological school, seen as weaker in the hierarchy of evidence, can be

viewed as contentious.

32

We do feel that using this combined methodology has a synergistic effect. This

approach is used increasingly in health services research (Adamson J 2005) and

funding bodies like the MRC increasingly expect a mixed method approach.

Mixing the methodologies, however, does produce difficulties in presenting the

data. Examples include difficulties with the basic structures of manuscripts, such

as listing study aims, which are to be expected in quantitative studies but run

counter to the exploratory nature of qualitative work where the research process

is expected to generate new concepts which may be unanticipated. The most

obvious tension is the expectation that we will critically appraise or judge the

quality of the qualitative literature that we include. This idea of prejudging the

qualitative literature runs counter to what we are trying to achieve with these data

sources, where we are hoping to elicit new concepts or themes, and the source

of that idea may come from a student letter or a faculty authored comment in a

high quality observational study. Examples of this strength of synthesis are

issues around student debt, which is a very strong theme from within the student

sources, but is largely absent from faculty sources, but perhaps explains some of

the reasoning behind students opting not to do iBScs, reasoning which is more

complex than pure academic attainment.

Our work operationalised the concept of the better doctor to three measurable

domains: we acknowledge that this concept may include many other attributes;

there is, however, little agreement about these attributes in the literature or data

about them to explore this area of analysis further.

Many of the studies within the statistical meta-analytic part of the review were of

low quality; the wide ORs reflect the small study sample sizes, and there was

also considerable heterogeneity in the results. Observational studies also have

problems of confounding and selection-bias; in some institutions the most

academically proficient medical students are those likely to be offered the option

to undertake iBScs. While we attempted to identify such effects, unrecognised

33

bias may have occurred. Nicholson et al.’s work additionally suggests financial

constraints; possibly an unrecognised confounder as it suggests a bias against

students from lower income backgrounds, perhaps struggling with debt or part-

time work or other issues that may impact on performance and this may be an

issue among those who don’t take up BScs (Nicholson, Cleland, Lemon, &

Galley 2010).

Within those studies analysed in the CIS component of the study we recognise

the need to be cautious; just because opinion leaders say their courses improve

aspects of students’ intellectual development does not mean this is necessarily

true. We also suspect an inherent bias in published material as there are strong

motivations for students and organisers to write about successful outcomes to

their courses. However, this data is remarkably consistent and informants who

appear to have no obvious conflict of interest (Smith 1986) make similar claims

of benefit from such courses.

We acknowledge that iBSc degrees are also a heterogeneous intervention (for

example: compare an iBSc physiology and one in international health). Expecting

to see a consistent impact on any one measure, such as undergraduate finals,

may, therefore, not be reasonable.

However, despite these concerns about some of the original data and limitations

of our analyses, there are consistent patterns, validated across both

methodologies, across countries, and over time, suggesting that iBScs can have

a beneficial effect on students in UG medical education.

Links to other literature

Previous reviews on this subject are available (Leung W 2001) (Collins, Farish,

McCalman, & McColl 2010). Leung’s review aimed at a student readership is

comprehensive but is a non systematic review of the literature and the source

studies were not appraised. The review by Leung was published in 2001, so is

34

now 11 years old, and misses some of the more recent methodologically higher

quality studies, particularly those that cast some doubt on the beneficial impact of

iBScs on UG performance. Collins et al. (2010), while more recent, is not

primarily a review of the literature, but as part of the discussion pulls together

much of this background material in a non systematic manner and includes some

UK and international policy documentation. This current review, therefore,

brings previous reviews up to date (with searches updated to late 2012), adds

critique of the primary studies and does so in a systematic manner across both

the qualitative and quantitative research traditions.

Previous research also confirmed that there is a beneficial effect of an extra year

of study and maturity on students’ exam performance (Wilkinson et al. 2004).

The effects we report on UG performance particularly may, therefore, not be

arising from the iBSc but due to increasing student maturity from an extra year of

study. Mahesan et al. report, however, that the extended MB BS course students

do slightly worse than students undertaking the normal length course.

Additionally, there seem to be no effect with year of intercalation suggesting a

diminution of effect on exam performance with time (Mahesan, Crichton, Sewell,

& Howell 2011). These indirect pieces of evidence suggest additional student

maturity may not be a key factor in our findings.

Conclusion

This review shows that iBScs may be a useful addition to the standard medical

undergraduate curriculum in terms of impact on student performance, skills

development and may positively impact on students’ employability and

subsequent careers. The more recent studies give conflicting answers about the

impact of iBSc on student performance.

The CIS data adds new insights into the students’ perspective on iBScs, enabling

the appreciation of positive and negative student commentaries alike.

35

The increasing impact of course fees and other costs will have a heavy impact on

students’ decisions about such courses. In a time of austerity, the role of iBScs,

as part of an already expensive medical course, is likely to come under close

scrutiny. It is uncertain whether the potential benefits of iBScs could be squeezed

into student selected components or into the ever expanding main medical

career. Such interventions, while probably demonstrating improved student skills,

may well harm the intangible benefits of iBSc courses that are not measureable,

such as enhanced scientific curiosity and intellectual development.

There is some suggestion that the benefits of increased research training seen

with iBScs might be being rebranded by institutions, and resources moved, to

develop combined medicine / higher research degree programmes (such as

MSs/MD/PhDs) (Creavin, Mallen, & Hays 2010) to benefit from the greater

marketability, status and international recognition attached to such degrees.

There is scope for future research regarding iBScs in medical education, as this

review has demonstrated. Neither this review, nor any of the identified papers,

addresse the question, what exactly is the function of an iBSc degree? Is it to

seed new medical academics (the institutional focus) or is to help make better

doctors (the societal focus)?

Cross institutional or even international collaboration may help define the

objectives, and delineate the potential benefits of these courses. Semi-structured

interviews with or surveys of students and academic stakeholders, or discourse

analysis of student internet blogs on the subject

(http://www.thestudentroom.co.uk/wiki/A_Brief_Guide_to_Intercalated_Degrees)

(tinyurl.com/6vz75o9), represent interesting possibilities for further work.

Educational practice and policy implications

36

Medical schools that offer optional iBScs need clear equitable selection policies

that don’t disadvantage able students from poorer backgrounds.

Course designers should have clear aims for these courses, and these aims

need to consider clear societal benefits, i.e. producing better doctors.

There should be a diversity of courses offered by medical schools with a

rebalancing towards more clinically related subjects

Medical schools that offer these courses should have clear generic objectives

across all their iBScs which go beyond a narrow disciplinary focus.

National research funding bodies should (again) consider supporting these

courses as they clearly impact on career choices of aspiring medical academics.

There should be more evaluations of such courses, particularly of those courses

that are less successful (so that lessons can be learnt by other institutions).

Practice points

There is evidence that:-

intercalated BScs may improve subsequent undergraduate performance.

iBScs are associated with increased chance of students pursuing

academic medical careers.

The educational experiences of these courses are often (but not

universally) very rich, and students may develop skills in areas that

traditional undergraduate courses struggle to provide.

These courses are expensive for students, faculty and funding bodies and

they delay workforce entry.

37

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46

Appendix 1 Meta-analysis- data sources

Author Outcome measure methods/ analysis commentary included Reason

1 Mahesan et al 2011 Finals exam performance

and early PG career

linear regression analysis School where > 50% do iBSc Yes High quality study adjusting for prior

performance and other baseline factors

2 Howman et al 2011 Summative marks for year 3

(1st clinical year). iBSc

taken before or after exam.

Multi-variate analysis of cross

sectional data.

School where all non graduates

undertake iBSc reducing risk of

selection bias (Author COI)

Yes High quality study adjusting for prior

performance and other baseline factors (NB

author COI)

3 Cleland et al 2009 Summative MB BS degree

assessments taken after

intercalating.

Univariate and Multinomial

logistic regression

School where 1/3 of student intercalate,

selection largely on academic

performance

Yes High quality study adjusting for prior

performance and other baseline factors

4 Gerrard et al 1988 Career outcome and

publication record

Case control iBsc students

compared with non BSc

students

Controlled for demographic profile and

prior acadmic performance

Yes High quality study controlling for a range of

potential confounders

5 Wyllie et al 1986 Finals performance and

career

case control matched on prior

performance

60 Pathology iBSc students matched

with non iBSC

Yes High quality study adjusting for prior

performance and other baseline factors

Studies not included in meta-analysis

6 McManus et al 1999 Study habits (surface, deep, and strategic learning style) and interest in different medical careers, including

medical research.

Longitudinal questionnaire

(prospective) multilevel

modelling and multiple

regression.

Large multicentre study Yes Very high quality study adjusting for prior

performance and other baseline factors, but no

data relating to review outcomes apart from

careers.

7 Tait & Marshall 1995 marks in clinical exams

subsequent to iBSc.

case control study compares

with gender / academically

matched non IBSc students

Very small numbers n=14 in iBSc group

multiple measures of student

performance recorded

Yes Moderate quality study

Studies included for data on GP career impact (broader selection criteria)

8 Eaton & Thong 1985

and 1986

(2 versions)

finals performance, careers

and academic measures

Retrospective case control study Australian study following students

through to postgraduate training

Yes (for GP

career

analysis only)

some matching but not controlled for prior

performance

9 Lambert et al (Med Ed

2001)

GP career by iBSc status Retrospective survey of UK

graduates looking at reported

Study will not account for those who do

not complete UG course

Yes (for GP

career

Large nationally representative survey no

adjustment for prior academic performance

47

BSc participation analysis only)

10 MacGowan et al 1986 Academic output (papers)

and career destination

Descriptive no data on

comparator groups (estimated

from national data)

Case series of students completing B

Med Biol degree

Yes (for GP

career only)

Some source data for careers only

11 Williamson 1986 Subsequent Career and

academic activity

Descriptive series from 1

institution, no comparator group.

Comparator data obtained form

from national data source

Retrospective survey Yes (for GP

career data

only)

Some source data for careers only

12 Ngyuyen et al 2001 examine career choice of medical students who completed an honours year in public health & epidemiology

descriptive analysis Case series of public health/

epidemiology intercalated honours

degree

Yes (for GP

career data

only)

Some source data for careers only

13 Young & Sefton 1984 subsequent careers case series no comparator group Yes (GP

career data

only)

Some source data for careers only

Studies not included

14 Elwood et al 1986

(JECH)

Case series (largely similar

data set to BMJ letter &

Nguyen data)

Descriptive Case series no comparator group No no comparator group

15 Elwood (2) et al (BMJ

letter) 1986

Case series (earlier data

to1986 study and Nguyen

data)

Descriptive no comparator group No Data not usable

16 Wakeford & Evered

1985

UG performance of Profs

and reader

Case control study Not prospective data No will not capture prospective effect of BSc

17 Collins et al 2010 Large Australian case series

of iBSc students

Case series no comparator group No no comparator group (and cannot reliably use

UK comparator groups)

18 Harris 1986 Series of iBSc students-

some data on subsequent

academic progression

Case series descriptive no comparator group No Data not usable

19 Nade et al 1978 Retrospective survey of

higher degree holder

Descriptive no comparator

groups

retrospective No Data unusable in this review

48

Appendix 2: data sources for the critical interpretive synthesis

Author Type of data source Formal

qualitative

analysis

Commentary includ

ed

Reason

1 Agha and Howell 2005 Study aimed at student attitudes to

(dis)benefits of doing iBSc

No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

2 Agha and Singh 2003 Letter In journal of record No Student letter reflecting on personal

development during an iBSc

Yes Useful student informant data

3 Al-Shaqzi 2010 Peer reviewed article (NZ) “To intercalate or not to intercalate”

No Contextual info by student about new iBSc

course

Yes Useful student informant data

4 Asgari-Jihandeh & Haywood1997 Short report in peer reviewed

journal

No Useful contextual information about skills

acquisition from iBSc

Yes Useful student informant data

5 Aston 2001 Student BMJ (sBMJ) letter No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

6 Attwell et al1986 Lancet letter No External stakeholder opinion on role of iBSc Yes Useful external stakeholder

informant data

7 Burkitt Wright 2001 Letter sBMJ No Data on career impact and finance Yes Useful student informant data

8 Broome et al 2007 Peer review paper on students’

views

Yes Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

9 Collier K 2001 sBMJ letter on iBSc research No Source of data on student perspective about

merits of undertaking research (negative

opinion)

Yes Useful student informant data (and a

divergent voice)

10 Dudley (ANZJ Surg) 1989 Descriptive piece of Australian course

No Faculty opinion Yes Useful faculty informant data

11 Emmel/ Goldstein 2002 sBMJ article on BSc international health/ student perspective

No Some comment on benefits of IBSc Yes Useful student informant data

49

12 Evered et al 1987 BMJ peer review article No Evidence on provenance of medical

researchers including iBSc

Yes Useful professional (clinician/

academic ) informant data

13 Fingerote (& Gerrard author reply)

1989

CMAJ letter No Qualified clinician perspective on financial

barriers to iBSc

Yes Useful professional (clinician)

informant data

14 Gerrard et al 1988 Peer review article (Canada) No Some faculty insights in predominantly

quantitative study

Yes Useful faculty informant data

15 Gardner et al 2008 sBMJ article on benefits of an iBSc No Student and clinician perspective on iBSc Yes Useful professional (clinician) and

student informant data

16 Gray 1989 Editorial No Faculty perspective on iBSc funding Yes Useful faculty informant data

17 Goldie et al 2004 Peer reviewed article (Med Ed) No study data on students’ handling ethical

issues

Yes Useful data about (adverse)

impact on student skills

18 Greenhalgh and Wong 2003 Editorial (commentary) No Faculty opinion on role of iBSc Yes Useful faculty informant data

19 Gutenstein 2000 sBMJ giving data on medical

education costs

No Source of data on course costs Yes Costs data

20 Harris 1986 BMJ letter No Course description/ outcome No Mainly quantitative data

21 Holgate et al 1999 (BMJ) Rapid response to

McManus

No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

22 Holmes 1986 BMJ letter No Qualified clinician perspective on benefits of

iBSc

Yes Useful professional (GP) informant

data

23 Iqbal 2001 Letter sBMJ No Useful contextual information about skills

acquisition from iBSc

Yes Useful student informant data

24 Jones, Singh, Lloyd 2001 Peer review article on an IBSc

(author COI)

No Faculty opinion on role of iBSc Yes Useful faculty informant data

(Author COI)

25 Jones et al 2005 Peer review article on an IBSc

(author COI)

Yes Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

(Author COI)

26 Jones et al 2008 Peer review article on an IBSc

(author COI)

Yes Useful contextual information about student

and faculty opinion on iBSc courses/ skills

acquisition

Yes Useful student / faculty informant

data (Author COI)

27 Kentish/ Avkiran 2002 Response to Krishnan and No Useful contextual information on student Yes Useful student/faculty informant

50

Krishnan partial retraction and faculty perception of project roles data (and a negative voice/

divergent data)

28 Krishnan 2002 Letter sBMJ No Useful contextual information about skills

acquisition from iBSc (rare adverse student

comment- subsequently retracted)

Yes Useful student informant data (and

a negative voice/ divergent data)

29 Leung W 2001 Article to student about merits

doing an iBSc

No Opinion on merits of IBSc for jobs Yes Useful external informant data

30 Leung W 1999 Article aimed at students about

strengthening CV

No Opinion on merits of IBSc for jobs Yes Useful external informant data

31 Longmore HJA BMJ letter No Clinician stakeholder opinion(divergent)

about role ,of iBSc

Yes Useful clinician stakeholder

informant (divergent) data

32 Ludbrook 1989 Editorial No Faculty opinion on role of iBSc Yes Useful faculty informant data

33 Morrison 2004 Editorial Journal of record No Faculty opinion on long term impact of iBSc Yes Useful faculty informant data

34 Moscrop 2002 sBMJ letter No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

35 Nicholson et al 2010 Peer review article No Useful contextual information about student

opinion on non participation in iBSc courses

Yes Useful (divergent) student

informant data

36 Patel sBMJ 2001

sBMJ letter No Useful contextual information about student

opinion on iBSc courses and impact on

employment

Yes Useful student informant data

37 Price 1998 sBMJ letter No Intercalating helps personal development

and medical skills

Yes Useful student informant data

38 Rushforth 2004 Med ed editorial Academic medicine and intercalated degrees – the myth of student choice”

No Useful contextual information about student/

recent graduate opinion on iBSc courses

Yes Useful student / stakeholder

informant data

39 Smith R 1986 BMJ editorial No Clinician/ science publisher perspective on

iBSc

Yes Useful professional (BMJ editor)

informant data

40 Thiagamoorthy 2001 sBMJ letter No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

41 White R 2006 sBMJ article Tips on surviving a

iBSc

No Useful contextual information about student

opinion on iBSc courses

Yes Useful student informant data

51

42 Williamson 1986 BMJ letter No Useful contextual information about student

/faculty opinion on iBSc courses

Yes Useful student/ faculty informant

data

43 Wyliie et al 1986 Peer review article No Some faculty insights in predominantly

quantitative study

Yes Useful faculty informant data

44 Yudkin et al 2003 Lancet description of new course No Contextual info by faculty and student

about new iBSc course

Yes Useful student and faculty

informant data

45 Weidmann 1995 sBMJ No Useful contextual information about student

opinion on iBSc courses

Useful student and faculty

informant data

46 Park JNZMA No Useful information- survey of intercalated

graduates (but some intercalated higher

degrees)

yes Useful student informant data

52

Studies not included

Andriole el al 2008 US MD PhD students No Characteristics and Career Intentions of the

Emerging MD/PhD Workforce

No Outside scope of review

Barzansky 2000 US programme No Educational Programs in US Medical Schools No Outside scope of review

Child and Gupta 2009 sBMJ on pathology No Student and faculty view on merits of iBSc in

pathology

No Limited contextual information

Cursifen1995 Peer reviewed study No Research course but not intercalated degree No Outside scope of review

Creavin 2010 Description of new course No Intercalated course but at Masters level No Outside scope of review

Dudley (Br J Med Ed)

1970

Descriptive piece of Australian course

No Faculty opinion No Little usable data

Gogalniceaunu et al

2009

UG anatomy teaching No Brief description of iBSc anatomy teaching No Limited data

Griswold et al 1991 Peer reviewed paper No Summer research school No Outside scope of review

Jacobs & Cross 1995 Peer reviewed paper No Course description- research course No Outside scope of review

Johnson et al 2005 Comparison of med /non med students doing a BSc

No Not comparing 2 groups of Medical students No comparison of B.Med Sci (non

medical students) with med

students

Jones 1999 BMJ (Rapid response to

McManus)

No Faculty opinion (author COI) No Limited data

Kemph et al 1984 Peer review paper No Summer research school No Outside scope of review

Kolcic et al 2005 Peer review journal No Research training programme No Outside scope of review

MacGowan et al1986 BMJ letter No Course description/ outcome No Mainly quantitative data

Piele & Johnson 2008 sBMJ article on academic medicine

No Some comment on benefits of IBSc No Insufficient contextual information

Seltzer 1987 BMJ letter (response to Evered) No Comment on results No No useable data

Smith FG et al 2001 Peer review paper No Research training programme No Outside scope of review

Smith R BMJ 1988 Review on medical research training

No Some review of data on IBsc No Data used in meta-analysis

Tamber 1986 News article on MRC withdrawal of funding for BSc

No Limited data on funders stakeholder opinion No Limited data

Villaneuva 2007 sBMJ article No Some contextual information about student opinion No Too brief to be useful

53

on iBSc courses

Wakeford et al1985 Lancet peer reviewed article No Evidence on provenance of medical researchers

including iBSc

No Too focused question for this review

Wakeford 1995 Med Ed letter (Response to Tait

paper)

No No new data No Highlights prev article